3 Angular Deformities Nomenclature Bow legsKnock kneesGenu VarusGenu Valgus
4 Angular Deformities Range of Normal Varies With Age During first year : Lateral bowing of TibiaeDuring second year : Bow legs (knees & tibiae)Between 3 – 4 years : Knock knees
5 Angular Deformities Evaluation Should differentiate between“physiologic” and “pathologic”deformities
6 Angular Deformities Evaluation PhysiologicPathologicSymmetricalAsymmetricalMild – moderateSevereProgressiveRegressiveGeneralizedLocalizedExpected for ageNot expected for age
7 Angular Deformities Causes PhysiologicPathologicNormal – for ageRicketsExaggerated :Endocrine disturbanceMetabolic disease- OverweightInjury to Epiphys. PlateInfection / Trauma- Early wt. bearing- Use of walker?Idiopathic
17 Angular Deformities Evaluation Investigations / RadiologicalX-ray when severe or possibly pathologicStanding AP filmlong film ( hips to ankles ) with patellae directed forwardsLook for diseases :Rickets / Tibia vara (Blount’s) / Epiphyseal injury..Measure angles.
22 Rotational LL Deformities In-toeing / Ex-toeingFrequently seen.Concerns parents.Frequently prompts varieties of treatment.( often un-necessary / incorrect )
23 Rotational Deformities Level of affection :FemurTibiaFoot
24 Rotational Deformities Femur Ante-version = more medial rotationRetro-version = more lateral rotation
25 Rotational Deformities Normal Development Femur : Ante-version :30 degrees at birth.10 degrees at maturity.Tibia : Lateral rotation :5 degrees at birth.15 degrees at maturity.
26 Rotational Deformities Normal Development Both Femur and Tibia laterally rotate with growth in childrenMedial Tibial torsion and Femoral ante-version improve ( reduce ) with time.Lateral Tibial torsion usually worsens with growth.
27 Rotational Deformities Clinical Examination Rotational ProfileAt which level is the rotational deformity?How severe is the rotational deformity?Four components:1- Foot propagation angle.2- Assess femoral rotational arc.3- Assess tibial rotational arc.4- Foot assessment.
33 Rotational Deformities Common Presentations InfantsOut-toeing : Normalseen when infant positioned upright( usually hips laterally rotate in-utero )Metatarsus adductus :medial deviation of forefoot90 % resolve spontaneouslycasting if rigid or persists late in 1st year
34 Rotational Deformities Common Presentations ToddlersIn-toeing most common during second year.( at beginning of walking )Causes :medial tibial torsion.metatarsus adductus.abducted great toe.
35 Rotational Deformities Common Presentations Toddlers - Medial Tibial TorsionThe commonest cause of in-toeingObservational management is bestAvoid special shoes / splints / bracesunnecessary, ineffective, interferes with activity and cause psychological and behavioral problems.
36 Rotational Deformities Common Presentations Toddler - Metatarsus AdductusSerial casting is effective in this age-groupUsually correctable by casting up to 4 years
37 Rotational Deformities Common Presentations Toddlers - Abducted Great ToeDynamic deformityOver-pull of Abductor Hallucis Muscle during stance phaseSpontaneously resolve - no treatment
38 Rotational Deformities Common Presentations Child In-toeing : due to medial femoral torsionOut-toeing : in late childhoodlateral femoral / tibial torsion
39 Usually: - starts at 3 - 5 years, - peaks at 4 – 6 years, Rotational Deformities Common Presentations Child Medial Femoral TorsionUsually: - starts at years,- peaks at 4 – 6 years,- then resolves spontaneously.Girls > boys.Look at relatives - family history – normal.Treatment usually not recommended.If persists > 8 years and severe, may need surgery.
40 Rotational Deformities Common Presentation Medial Femoral Torsion (Ante-version)Stands with knees medially rotated (kissing patellae).Sits in W position.Runs awkwardly (egg-beater).Family History
41 May be associated with knee pain (patellar) Rotational Deformities Common Presentations Child Lateral Tibial TorsionUsually worsens.May be associated with knee pain (patellar)specially if LTT is associated with MFT.( knee medially rotated and ankle laterally rotated )
42 Less common than LTT in older child May need surgery if : Rotational Deformities Common Presentations Child Medial Tibial TorsionLess common than LTT in older childMay need surgery if :persists > 8 year,and causes functional disability
43 Rotational Deformities Management Challenge : dealing effectively with familyIn-toeing : spontaneously corrects in vast majority of children as LL externally rotates with growth - Best Wait !
44 Rotational Deformities Management Convince family that only observation is appropriate< 1 % of femoral & tibial torsional deformities fail to resolve and may require surgery in late childhood.
45 Rotational Deformities Management Attempts to control child’s walking, sitting and sleeping positions is impossible and ineffective cause frustration and conflicts.She wedges and inserts : ineffective.Bracing with twisters :ineffective - and limits activity.Night splints : better tolerated - ? Benefit.
50 Leg Aches / Growing Pains Incidence : % of children.More In girls / At night / In LL.Diagnosis is made by exclusion.
51 Leg Aches / Growing Pains History Vague pain.Poorly localised.Bilateral.Nocturnal.Seldom alters activity.Long duration.
52 Leg Aches / Growing Pains Examination General health is normal.No deformities.No joint stiffness.No tenderness.Normal gait.No limping.
53 Leg Aches / Growing Pains Management When atypical history or signs present on examination:Imaging and lab. Studies.If all negative :Symptomatic treatment :Heat / Analgesics.Reassure family :Benign.Self-limiting.Advise to re-evaluate if clinical features change.
54 Leg Aches / Growing Pains FeatureGrowing PainSerious ProblemHistory :Long durationOftenUsually notPain localisedNoPain bilateralUnusualUlters activityCause limpingSometimesGeneral healthGoodMay be illFrom Stahili : Practice of Pediatric Orthopedics 2001
55 Leg Aches / Growing Pains FeatureGrowing PainSerious ProblemPhysical examination :TendernessNoMay showGuardingReduced rang of motionLaboratory :CBCNormal? AbnormalESRFrom Stahili : Practice of Pediatric Orthopedics 2001
58 CDH / DDH Congenital Dislocation of Hip. Developmental Dysplasia of Hip.
59 CDH Spectrum Teratologic Hip : Fixed dislocation Often with other anomaliesDislocated Hip : Completely outMay or may not be reducibleSubluxated Hip : Only partially inUnstable Hip : Femoral head can be dislocatedAcetabular Dysplasia : Shallow AcetabulumHead Subluxated or in place
60 CDH Etiology & Risk Factors Prenatal :Positive family history (increases risk 10X)Primi-gravidaFemale (4-6 X > Males)Oligo-hydramniousBreech position (increases risk 5-10 X)Postnatal :Swaddling / Strapping ( ? Knees extended)Ligament LaxityTorticollis (CDH in % cases)Cong. Knee recurvatum / dislocationMetatarsus adductus / calcaneo-valgus
61 CDH Risk Factors When Risk Factors Are Present The infant should be examined repeatedlyThe hip should be imaged byU/Sor X-ray
70 CDH Neonatal Examination Ortolani TestBarlow Test
71 CDH Clinical Examination Hip clicks :- fine, short duration, high pitched sounds- common and benign – from soft tissuesHip clunks :- sensation of the hip displacing over theacetabular marginIf in doubt : U/S in young infantssingle radiograph if > 2-3 months
73 CDH Ultrasound Screening Early U/S screening not recommendedDelayed U/S screening :Older than 3 weeksThose at risk or suspicious by:HistoryClinical exam
74 CDH Treatment Birth to 6 months : 6 months – 12 months : Pavlik harness or hip spica cast6 months – 12 months :closed reduction UGA and hip spica casts12 months – 18 months :possible closed / possible open reductionAbove 18 months :open reduction and ? AcetabuloplastyAbove 2 years :open reduction,acetabulplasty, and femoral osteotomy
75 The earlier started, the easier the treatment & the better the results CDH TreatmentMethod depends on AgeThe earlier started, the easier the treatment & the better the resultsShould be detected EARLYUREGENT referral once an abnormality is detected.